The COVID Complication You Might Miss

Brendan R. Jackson, MD, MPH; Pavithra Natarajan, BMBS


November 19, 2020

Editorial Collaboration

Medscape &

Hospital Course  

In critically ill patients without typical aspergillosis risk factors, such as prolonged neutropenia and immunosuppressive medications, radiologic changes are usually nonspecific and can include pulmonary infiltrates, consolidation, and nodules. Radiologic features such as halo sign, air-crescent sign, or cavitation are rare.

First-line options for treatment are either intravenous voriconazole (loading dose 6 mg/kg body weight twice a day on day 1; 4 mg/kg body weight twice a day on day 2) or intravenous isavuconazole (loading dose 200 mg three times a day on days 1 and 2, followed by 200 mg daily thereafter). Therapeutic drug monitoring is recommended.

Consideration should be given to the local antifungal resistance situation, and management should involve consultation with an infectious disease physician.

Liposomal amphotericin B, posaconazole, and echinocandins are second-line options that can be used in refractory cases or when first-line options are contraindicated or not feasible.

Despite treatment with intravenous voriconazole, the patient's respiratory status continues to deteriorate, and she dies 2 days later of respiratory failure. Sadly, this is consistent with what we know about mortality from CAPA, which has been found to be as high as two thirds in some series.


Aspergillosis is emerging as a deadly complication of severe influenza and COVID-19, but one of which many US healthcare providers remain unaware. As a result, delays in diagnosis or misdiagnoses occur, probably leading to increased mortality from aspergillosis.

Any patient with severe COVID-19 may be at risk for CAPA, and widespread adjunctive use of dexamethasone for management of severe COVID-19 prompts additional concern for secondary aspergillosis. Healthcare providers treating critically ill patients with COVID-19 should consider aspergillosis and know how to detect this emerging complication.

Brendan R. Jackson, MD, MPH, serves as the lead for the epidemiology team in the mycotic diseases branch at the CDC.

Pavithra Natarajan, BMBS, is a medical officer in the mycotic diseases branch at the CDC.

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